The retained surgical sponge following intra-abdominal surgery. A continuing problem

Management of abdominal textilomas: A retrospective study

INTRODUCTION

Textilomas are an infrequent but well-known surgical complication. The authors report a series of cases to describe the frequency of abdominal textilomas, the circumstances in which they occur, their clinical and morphological characteristics, and their management, to contextualise these data, which may serve as a basis for preventive measures.

SETTING AND METHOD

This was a monocentric, retrospective, descriptive study conducted over 10 years at a tertiary hospital. The circumstances of the initial intervention, the diagnosis, and the treatment of textiloma cases treated in the said centre were documented.

RESULTS

Twenty-one (21) cases of abdominal textiloma were collected, with an annual frequency of 2.1 cases/year. The cases were predominantly female, with a female-to-male sex ratio of 1.62. The median age of the patients was 37 years. The initial operation was performed in a public facility in 80.95 % of cases. Myomectomy was the main indication (23.81 %). The time for signs to develop before consultation was 16.47 ± 8.82 days. Textiloma extraction was performed in an emergency in 61.90 % of cases. We noted morbidity (38.10 %) and mortality (9.52 %) in our patients.

CONCLUSION

Textilomas are a rare surgical complication, albeit with a high morbidity and mortality rate. Their clinical polymorphism and the difficulties of diagnosis and management mean that prevention is of prime importance.

Breakage of a Pituitary Rongeur Tip: An Unforeseen Complication of Lumbar Microdiscectomy: A Case Report and Review of Literature

CASE

A 46-year-old man with left leg radiculopathy due to a left L4-5 disc extrusion had a lumbar microdiscectomy that was complicated by the pituitary rongeur tip breaking in the L4-5 disc space. The rongeur tip was successfully retrieved by widening the entry access without damaging the adjoining facet and utilizing a blunt nerve hook and probe dissector.

CONCLUSION

Breakage of the pituitary rongeur tip is an unforeseen complication of lumbar microdiscectomy. Surgeons should be aware of this potential complication, ideally confirm the rongeur is intact prior to wound coverage, and understand the risks versus benefits of attempting to retrieve a broken rongeur tip.

Hidden retained surgical sponge with intestinal migration: A rare case report

Introduction and importance

Retained surgical items are mistakenly left items used during surgery. They are not always radiopaque and in literature there are numbers of case reports that were not found by X ray. Transmigration of the retained surgical item to the small intestine is one of the possible outcomes rarely seen in patients.

Case presentation

we present a case 32-year-old male with a history of open appendectomy one year ago presented to the emergency department with fever and diffuse abdominal cramps, which worsened after meals.

Clinical discussion

Lab tests, abdominal and pelvis sonography, x-rays and CT scan and small intestine series all were unremarkable and only after defecation of a surgical gauze with blue marker, the diagnosis was made.

Conclusion

In all missed items at the end of operation standard counting protocols must be considered and if we couldn't find the missed item never forget the meticulous follow ups because of a great chance of non-opaque item existence, in extremely rare cases the sponge could entered the bowels without obstruction or perforation and eventually defecated.

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Retained surgical items are mistakenly left items used during surgery.

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Transmigration of the retained surgical item to the small intestine is one of the possible outcomes rarely seen in patients.

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In all missed items at the end of operation standard counting protocols must be considered.

Giant gossypiboma presenting as a pelvic mass

Gossypiboma is a foreign object, such as a mass of cotton matrix or a sponge, that is left behind in a body cavity during surgery. It is uncommon, mostly asymptomatic, and hard to diagnose. It may be incorrectly diagnosed preoperatively, which can lead to unnecessary invasive diagnostic procedures and operations. It should be included in the differential diagnosis of soft-tissue masses detected in patients with a history of a prior operation. We present a case of 36-year-old female who referred to emergency room with severe abdominal pain and distension. Imaging revealed a giant intra-abdominal mass resembling a soft tissue tumor, but revealed to be a giant gossypiboma caused by a sponge that was forgotten during previous ectopic pregnancy surgery. This case differs from others with the absence of findings supporting gossypiboma such as calcification or trapped gas bubbles and emphasizes the importance of this potentially life-threatening complication of surgery.

Sonographic appearance of a soft-tissue gossypiboma in the forearm with pathologic correlation

We describe the sonographic, radiologic, and histopathologic appearances of a soft tissue gossypiboma in the forearm of an 81-year-old woman with a history of a radial fracture treated with an internal fixation surgery.

Incidence, root cause, and outcomes of unintentionally retained intraabdominal surgical sponges: a retrospective case series from two hospitals in Togo

Background

The term gossypiboma refers to a sponge that has been forgotten in the surgical field. It is the most common retained surgical item, and constitutes a continuing problem for surgical safety. We performed a hospital-based study to examine their incidence, root cause, and outcomes, as an effort toward improving prevention.

Methods

This retrospective study covered 10 years (2006-2015) and included surgically confirmed cases of abdominal gossypibomas occurring after 45,011 abdominal and gynaecological operations in 2 public hospitals in Lome (Togo). Age, diagnosis, initial surgical procedure, evidence of textile count, and data related to the revision procedure were collected for descriptive analysis.

Results

Fifteen cases of gossypibomas (11 women and 4 men) were recorded. The mean age of the patients was 27 (range 21-55) years. Initial procedures were gynaecological in 11 patients and 5 cases involved an emergency surgery. Evidence of sponge counting was found in 6cases. Gossypiboma was an incidental finding in 1 patient. The average time to onset of symptoms after the initial procedure was 2 months. The gossypiboma was removed within 7 days to 4 years after the initial procedure. Postoperative complications included enterocutaneous fistula in 2 patients, incisional hernia in 2 patients, and wound sepsis in 1 patient. Death occurred in 2 patients (13.3%).

Conclusions

Although rare, the incidence of gossypibomas is still unacceptably high and reveals failures regarding patient safety standards. The associated morbidity and mortality are significant, yet can be reduced by an early diagnosis in the immediate postoperative period. A systematic methodical count of sponges is the cornerstone of prevention, and introducing surgical safety protocols, such as the WHO Safe Surgery Saves Lives checklist, can enhance effectiveness. There is a crucial need for safety-focused policies, which may include a never event reporting system, elaboration of prevention strategies, interventions, and evaluation.

Unintentionally retained foreign bodies after surgical procedures. Analysis of 4547 cases

OBJECTIVE

this study aims to explore the experience of Brazilian surgeons on Unintentionally Retained Foreign Bodies (RFB) after surgical procedures.

METHODS

A questionnaire was sent to surgeons by electronic mail, between March and July 2012. The questions analyzed their experience with foreign bodies (FB), foreign bodies' types, clinical manifestations, diagnoses, risk factors and legal implications.

RESULTS

in the 2872 eligible questionnaires, 43% of the surgeons asserted that they had already left FB and 73% had removed FB in one or more occasions, totalizing 4547. Of these foreign bodies, 90% were textiles, 78% were discovered in the first year and 14% remained asymptomatic. Among doctors with less than five years after graduation, 36% had already left a FB. The most frequently surgical procedures mentioned were the elective (57%) and routine (85%) ones. Emergency (26%), lack of counting (25%) and inadequate conditions of work contributed (12.5%) to the occurrence. In 46% of the cases patients were alerted about the FB, and 26% of them sued the doctors or the institution.

CONCLUSIONS

challenging medical situations, omission of security protocols and inadequate work conditions contributed to RFB. However, RFB occurs mostly in routine procedures such as cesarean or cholecystectomy, and at the beginning of the professional career, highlighting, particularly in poorest countries, the need for primary prevention. Textiles predominated causing clinical repercussions and they were diagnosed in the first postoperative months. Surgeons were sued in 11.3% of the RFB cases.

Pelvic gossypiboma with spontaneous intravesical erosion

A 23-year-old man presented with chronic lower urinary tract symptoms and right flank pain. He had undergone ureterolithotomy a few years ago. Ultrasonography and CT of the abdomen and pelvis showed a right paravesical mass and proximal hydroureteronephrosis. Cystoscopic examination revealed a part of surgical gauze embedded in the right lateral wall of the bladder. The surgical gauze was completely retrieved with grasping forceps without any additional procedures. The patient experienced prompt relief of his symptoms and at follow-up, imaging studies revealed resolution of the pelvic mass and non-obstructed clearance of right-side collecting system. Pelvic gossypiboma with partial intravesical erosion is an unusual presentation and can be managed successfully by cystoscopic manipulation.

Gossypibomas, a surgeon's nightmare-patient demographics, risk factors, imaging and how we can prevent it

OBJECTIVE

Gossypibomas are a cottonoid matrix left behind following surgery. Owing to the legal issues associated with it, very few literature studies are available online, most of them being case reports. The purpose of our study was to identify the patient demographics, risk factors and imaging features.

METHODS

Six surgically identified and histopathologically confirmed cases of gossypibomas recorded over a period of 5 years from a single tertiary institution were retrospectively evaluated for patient demographics [sex, age, body mass index (BMI)], type of surgery and duration from time of surgery to onset of symptoms. Ultrasound and CT images obtained from our hospital database were evaluated for their characteristic pattern. Statistics used included percentage and frequency.

RESULTS

Females formed the bulk of our patients and the mean BMI of our patients was 24.25. The interval between surgery and symptom presentation ranged from 2 months to 7 years. The most common imaging patterns observed on ultrasound and CT were a thick-walled hypoechoic lesion with a strong posterior acoustic shadowing and a "spongiform pattern", respectively.

CONCLUSION

A detailed patient history, taking into account radiologist-surgeon interaction, along with familiarization of the various risk factors and imaging patterns can bring about an accurate diagnosis of a gossypiboma. Advances in knowledge: Our study showed that the female sex, especially those undergoing gynaecology-related surgery such as hysterectomy and patients with a high BMI were at risk of gossypibomas. The combination of a hypoechoic lesion with strong posterior shadowing on ultrasound along with a spongiform pattern on CT was highly characteristic for gossypiboma on imaging.

Gossypiboma with bleeding from fistula to the colon observed by colonoscopy

A gossypiboma is a mass of cotton sponge left in the body postoperatively. Here, we report a case of gossypiboma with bleeding through a fistula to the colon, which became clinically evident 24 years after gynecological surgery, and resembled a bleeding diverticulum at colonoscopy. A 67-year-old woman presented with anemia and hematochezia. She had undergone a hysterectomy for myoma uteri 24 years earlier. Colonoscopy showed a deep depressed lesion mimicking a diverticulum with bleeding in the transverse colon. A contrast-enhanced computed tomography was interpreted as revealing a 6-cm thick-walled tumor, containing an air bubble, and a fistula between the mass and the transverse colon. The patient underwent laparotomy, with the preoperative expectation that the mass was a penetrating submucosal tumor. Pathological findings revealed denatured cotton tissues surrounded by reactive tissues to the foreign body. Despite its rarity, gossypiboma should be considered in patients with an intra-abdominal mass who have a history of laparotomy. Gossypiboma can cause fistula to the colon and bleeding. Imaging studies and the clinical course may mimic a malignant tumor.

Endoscopic removal of a retained surgical sponge in a young Syrian refugee after Caesarean section: a case report with discussion of cultural and political consequences

Background

Inadvertently retained sponges and instruments still constitute a major but preventable complication in surgery. Given the high geographic mobility of patients, the fluctuation of physician-patient contact, and communication problems due to language barriers, the conscientious use of structured safety protocols in clinical routine is an essential aspect of quality in health care.

Case presentation

We report the case of a 24-year-old refugee from Syria who presented at our gynecological outpatient department with a tumor in the lower abdomen, suspected to be a lump in the ovary or the uterus. Language barriers hindered exact recording of the patient’s medical history. We knew she had undergone three Caesarean sections several years ago. The diagnostic laparoscopy unexpectedly revealed a tumor suspected to be a retained surgical sponge. The lesion was removed completely and the patient discharged from the clinic five days later.

Conclusion

In ambiguous cases, the diagnostic and therapeutic potential of minimally invasive surgery ensures safe and effective treatment of the patient, a short hospital stay, and low rates of complications. Especially in cases of language and/or cultural barriers, structured safety protocols should be a part of clinical routine in order to prevent unnecessary complications.

Surgical sponge forgotten for nine years in the abdomen: A case report

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Gossypiboma consist in retained surgical sponges are more usual than the reported.

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A young patient nine years after cesarean section with abdominal pain and fever.

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An abscess was diagnosed in the lower abdomen by CT.

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During laparotomy, a sponge was extracted from a large abscess.

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She had a normal post-operative course.

Introduction

Retained surgical sponge or other items in patients’ bodies happens more frequently than is reported. Healthcare personnel can forget to remove textile material or instruments during complicated, extended, or emergency surgery. In addition, changes in the operating team can influence the occurrence of such errors.

Presentation of case

We present a case with a symptomatic gossypiboma nine years after a previous cesarean section. A 34-year-old woman was admitted to the emergency room having experienced abdominal pain and fever for the previous month. An abdominal computed tomography revealed an abscess in the lower abdomen.

A laparotomy was performed, and a resection and block were carried out. A surgical sponge was extracted from an omental abscess.

Discussion

Surgical sponges are the most common foreign materials retained (70%) in the abdominal cavity because of their frequent usage and small size. Moreover, a blood-soaked sponge in a hemorrhagic abdomen can be difficult to distinguish from blood.

Conclusion

Whenever the accounting for material depends on humans, mistakes will continue to be committed.

A falsely correct sponge count was reported in 71.42% of cases [14]; therefore, a new count system must be developed for post-surgical situations.

Surgicel® granuloma mimicking ovarian cancer: A case report

Surgicel^® is an absorbable sterile mesh composed of oxidized cellulose that is used to control intraoperative capillary or venous bleeding, due to its capacity to bind hemoglobin, thus allowing the formation of an artificial clot. In the present study, a large granuloma mimicking ovarian cancer, which developed following placement of a Surgicel^® sponge during a combined pubovaginal sling procedure and cystocele repair, is reported. The aim of the present case report is to emphasize the fact that hemostatic measures should be removed following their use, and to alert surgeons to the risk of using and leaving in situ oxidized cellulose. Furthermore, accurate evaluation of the surgical history of the patient should always be performed prior to attempting surgery.

Computer aided detection of surgical retained foreign object for prevention

PURPOSE

Surgical retained foreign objects (RFOs) have significant morbidity and mortality. They are associated with approximately $1.5 × 10(9) annually in preventable medical costs. The detection accuracy of radiographs for RFOs is a mediocre 59%. The authors address the RFO problem with two complementary technologies: a three-dimensional (3D) gossypiboma micro tag, the μTag that improves the visibility of RFOs on radiographs, and a computer aided detection (CAD) system that detects the μTag. It is desirable for the CAD system to operate in a high specificity mode in the operating room (OR) and function as a first reader for the surgeon. This allows for fast point of care results and seamless workflow integration. The CAD system can also operate in a high sensitivity mode as a second reader for the radiologist to ensure the highest possible detection accuracy.

METHODS

The 3D geometry of the μTag produces a similar two dimensional (2D) depiction on radiographs regardless of its orientation in the human body and ensures accurate detection by a radiologist and the CAD. The authors created a data set of 1800 cadaver images with the 3D μTag and other common man-made surgical objects positioned randomly. A total of 1061 cadaver images contained a single μTag and the remaining 739 were without μTag. A radiologist marked the location of the μTag using an in-house developed graphical user interface. The data set was partitioned into three independent subsets: a training set, a validation set, and a test set, consisting of 540, 560, and 700 images, respectively. A CAD system with modules that included preprocessing μTag enhancement, labeling, segmentation, feature analysis, classification, and detection was developed. The CAD system was developed using the training and the validation sets.

RESULTS

On the training set, the CAD achieved 81.5% sensitivity with 0.014 false positives (FPs) per image in a high specificity mode for the surgeons in the OR and 96.1% sensitivity with 0.81 FPs per image in a high sensitivity mode for the radiologists. On the independent test set, the CAD achieved 79.5% sensitivity with 0.003 FPs per image in a high specificity mode for the surgeons and 90.2% sensitivity with 0.23 FPs per image in a high sensitivity mode for the radiologists.

CONCLUSIONS

To the best of the authors' knowledge, this is the first time a 3D μTag is used to produce a recognizable, substantially similar 2D projection on radiographs regardless of orientation in space. It is the first time a CAD system is used to search for man-made objects over anatomic background. The CAD system for the μTags achieved reasonable performance in both the high specificity and the high sensitivity modes.

Inflammatory gossypiboma in young female athlete

Retained surgical gauze that was left inside the patient during a surgical procedure is called gossypiboma or textiloma. It is a rare complication of surgery commonly seen after abdominal operations. The symptoms of gossypiboma are non-specific, such as pain, palpable mass and fever, which make clinical diagnosis difficult. We present a case of young female athlete patient with right lower quadrant (RLQ) pain for 1 month, caused by surgical gauze which was retained from previous cesarean delivery performed 24 yr ago. Patient with retained surgical gauze can be asymptomatic for a long period. In our case, laparoscopy was used as the diagnostic and therapeutic tool. This report discusses the approach to, and manifestations of gossypiboma which presents a long asymptomatic period.

Paravesical gossypiboma following inguinal herniorrhaphy: Laparoscopic retrieval

Retained surgical sponge (gossypiboma) following an inguinal herniorrhaphy is a rare condition and may cause medicolegal problems. Differential diagnosis for the lesion should be made meticulously. We report a case of a 45-year-old man who had a herniorrhaphy about 8 years previously. He presented one episode of painless gross hematuria. Laboratory and imaging studies excluded any significant lesion in the urological organs. Abdominal CT scan demonstrated a heterogeneous neoplasm of 4 cm in size in the left paravesical area that was retrieved laparoscopically. Abdominal CT and clinical suspicion are helpful for diagnosis. Laparoscopy may be used to confirm the diagnosis and to remove the retained surgical gauze, and considered as an alternative therapy for some selected patients.

Hospital and procedure incidence of pediatric retained surgical items

BACKGROUND

Prevention of retained surgical items (RSIs) is the main objective of the World Health Organization "Guidelines for Safe Surgery" (WHO/GSS) 2008 to improve patient safety.

METHODS

We analyzed Kids' Inpatient Database 1997-2009 for RSI in patients aged <18 y. Incidence of RSI was calculated by per 100,000 admissions and per 100,000 procedures. The incidence was analyzed based on hospital bedsize, teaching status, region, and ownership and rural versus metropolitan location based on per 100,000 admissions.

RESULTS

Overall, 713 cases were identified with a mean (standard deviation) age of 8.31 y (6.62), length of stay of 13 d (20), and total charges of $91,321 (155,054). RSI occurred at a rate of 2.22 per 100,000 admissions and 1.93 per 100,000 procedures; both rates decreased post-WHO/GSS implementation versus pre-WHO/GSS, P < 0.005. On average, public or children's hospitals reported the highest RSI rates (8.89 and 6.07/100,000 admissions, respectively). Small and medium bedsize hospitals had lower rates of RSI post-WHO/GSS, P < 0.05. Nonteaching, non-children's, or public hospitals reported lower rates post-WHO/GSS, P < 0.003. Private (nonprofit) hospitals reported higher rates post-WHO/GSS, P < 0.001. Facilities in the southern United States or in metropolitan areas reported lower rates post-WHO/GSS, P < 0.02. A subanalysis of 107 cases requiring surgical removal demonstrated that fundoplications had the highest rate of RSI, followed by gastric procedures, laparotomy, bile duct procedures, lysis of adhesions, and abdominal wall repair.

CONCLUSIONS

RSI rates have decreased overall after the introduction of the WHO/GSS. The largest reductions have occurred in public or nonteaching hospitals. Only private (nonprofit) hospitals reported increases in RSI since 2008. Higher rates of RSI are associated with fundoplications and other gastric procedures.

Gossypiboma mimicking as dermoid cyst of ovary: a case report

Gossypiboma is a rare condition caused by retained postoperative foreign bodies. The condition is under reported because of diagnostic difficulties and medicolegal implications associated with it. It may mimic a benign or malignant soft-tissue tumour in the abdomen and pelvis. A 22-year-old woman presented with non specific symptoms and was referred to us with radiological diagnosis of dermoid cyst. On laparotomy the mass was proved to be a gossypiboma resulted from gauze which was retained in caesarean section done two years back. Although gossypiboma is rarely seen in daily clinical practice, it should be considered in the differential diagnosis of postoperative patients presenting with non specific complains and lump abdomen. Despite thorough history, physical examination, laboratory, and radiographical findings, usually gossypibomas are not suspected and remain an accidental finding. Employment of all preventive measures during surgical procedures and high index of suspicion in post operative patients are the key stones in its management.

Post-nephrectomy foreign-body granuloma in the retroperitoneum mimicking lymph node metastasis of renal cell cancer

Recently, iatrogenic foreign-body granuloma has been increasingly reported. The asymptomatic presentation and confusing appearance of granuloma can lead to misdiagnosis of a secondary malignancy, especially for a patient with a corresponding past medical history. Sometimes, surgical treatment is unavoidable, and the diagnosis relies upon the pathologic result. Herein, we report an unusual case of a 43-year-old man who underwent a nephrectomy for renal cell carcinoma (clear cell type) 5 years ago. A secondary granuloma was identified behind the inferior vena cava in the retroperitoneum 6 months after the surgery, but the radiologists had failed to identify it throughout the 4 years of routine examination. Later on, the lesion was identified by positron emission tomography, which classified it as a highly 18F-fluorodeoxyglucose-avid lesion. Considering no visible foreign-bodies identified on images, the lesion was arguably diagnosed as a lymph node metastasis of renal cancer. Finally, it was confirmed as a foreign-body granuloma encasing surgical suture and adipose tissue by the pathological analysis.

Retained intra-abdominal surgical clamp complicating emergency laparotomy: incidental finding on hysterosalpingogram for evaluation of tubal infertility

The finding of intraperitoneal foreign body complicating surgical intervention broadly remains as an issue of safety in the operative room, a source of emotive concern for the patient, and an upsetting but equally embarrassing situation to the surgeon and the team. However, in the media world, it is a source of sumptuous and captivating headline on the newspaper and to the legal profession, an attractive case to prosecute. A middle age teacher presented with secondary infertility. She had emergency laparotomy fifteen years ago for ruptured tubal ectopic pregnancy in a private hospital and postoperative period was uneventful. Amongst other investigations to find out the cause of infertility, she had hysterosalpingography and a radio-opaque clamp was visualized on the films. She was counselled and had laparotomy. A pair of surgical Kocher clamps was retrieved buried in the mesentery.

Intractable duodenal ulcer caused by transmural migration of gossypiboma into the duodenum--a case report and literature review

Background

Gossypiboma is a term used to describe a mass that forms around a cotton sponge or abdominal compress accidentally left in a patient during surgery. Transmural migration of an intra-abdominal gossypiboma has been reported to occur in the digestive tract, bladder, vagina and diaphragm. Open surgery is the most common approach in the treatment of gossypiboma. However, gossypibomas can be extracted by endoscopy while migrating into the digestive tract. We report a case of intractable duodenal ulcer caused by transmural migration of gossypiboma successfully treated by duodenorrhaphy. A systemic literature review is provided and a scheme of the therapeutic approach is proposed.

Case presentation

A 61-year-old Han Chinese man presented with intermittent epigastric pain for the last 10 months. He had undergone laparoscopic cholecystectomy conversion to open cholecystectomy for acute gangrenous cholecystitis 10 months ago at another hospital. Transmural migration of gossypiboma into the duodenum was found. Endoscopic intervention failed to remove the entire gauze, and duodenal ulcer caused by the gauze persisted. Surgical intervention was performed and the gauze was removed successfully. The penetrated ulcer was repaired with duodenorrhaphy. The postoperative period was uneventful.

We systematically reviewed the literature on transmural migration of gossypiboma into duodenum and present an overview of published cases. Our PubMed search yielded seven reports of transmural migration of retained surgical sponge into the duodenum. Surgical interventions were necessary in two patients.

Conclusion

Transmural migration of gossypiboma into the duodenum is a rare surgical complication. The treatment strategies include endoscopic extraction and surgical intervention. Prompt surgical intervention should be considered for emergent conditions such as active bleeding, gastrointestinal obstruction, or intra-abdominal sepsis. For non-emergent conditions, surgical intervention could be considered for intractable cases in which endoscopic extraction failed.

Risk factors for retained surgical items: a meta-analysis and proposed risk stratification system

BACKGROUND

Retained surgical items (RSI) are designated as completely preventable "never events". Despite numerous case reports, clinical series, and expert opinions few studies provide quantitative insight into RSI risk factors and their relative contributions to the overall RSI risk profile. Existing case-control studies lack the ability to reliably detect clinically important differences within the long list of proposed risks. This meta-analysis examines the best available data for RSI risk factors, seeking to provide a clinically relevant risk stratification system.

METHODS

Nineteen candidate studies were considered for this meta-analysis. Three retrospective, case-control studies of RSI-related risk factors contained suitable group comparisons between patients with and without RSI, thus qualifying for further analysis. Comprehensive Meta-Analysis 2.0 (BioStat, Inc, Englewood, NJ) software was used to analyze the following "common factor" variables compiled from the above studies: body-mass index, emergency procedure, estimated operative blood loss >500 mL, incorrect surgical count, lack of surgical count, >1 subprocedure, >1 surgical team, nursing staff shift change, operation "afterhours" (i.e., between 5 PM and 7 AM), operative time, trainee presence, and unexpected intraoperative factors. We further stratified resulting RSI risk factors into low, intermediate, and high risk.

RESULTS

Despite the fact that only between three and six risk factors were associated with increased RSI risk across the three studies, our analysis of pooled data demonstrates that seven risk factors are significantly associated with increased RSI risk. Variables found to elevate the RSI risk include intraoperative blood loss >500 mL (odds ratio [OR] 1.6); duration of operation (OR 1.7); >1 subprocedure (OR 2.1); lack of surgical counts (OR 2.5); >1 surgical team (OR 3.0); unexpected intraoperative factors (OR 3.4); and incorrect surgical count (OR 6.1). Changes in nursing staff, emergency surgery, body-mass index, and operation "afterhours" were not significantly associated with increased RSI risk.

CONCLUSIONS

Among the "common risk factors" reported by all three case-control studies, seven synergistically show elevated RSI risk across the pooled data. Based on these results, we propose a risk stratification scheme and issue a call to arms for large, prospective, and multicenter studies evaluating effects of specific changes at the institutional level (i.e., universal surgical counts, radiographic verification of the absence of RSI, and radiofrequency labeling of surgical instruments and sponges) on the risk of RSI. Overall, our findings provide a meaningful foundation for future patient safety initiatives and clinical studies of RSI occurrence and prevention.

Robotic-assisted laparoscopic excision of gossypiboma simulating bladder wall mass after 35 years of appendectomy

Gossypiboma or textiloma are terms commonly used to describe a retained sponge in the body that is composed of sponge invested within a layer of foreign body reaction in the form of an abscess or an aseptic fibrotic reaction. These cases are rarely reported despite an incidence of 1:1,000-1,500 of abdominal or pelvic surgery. We report a patient who presented with an incidental supravesical mass discovered upon work up for frequency and suprapubic pain. He had appendectomy 35 years ago. The mass was excised by robotic-assisted laparoscopic technique. The pathologic evaluation came as gossypiboma.

Retained foreign bodies: a serious threat in the Indian operation room

Retained foreign bodies (RFBs) are a surgical complication resulting from foreign materials accidently left in a patient's body. This review attempts to give an overview of different types of RFBs, problems related to them and their management after the surgical operation. The internet was searched using the Google and Google scholar. In addition, relevant electronic journals from the University's library such as Entrez (including PubMed and PubMed central), Since Direct, Scirus, NIH.gov, Medknow.com, Medscape.com, Scopus, MedHelp.org, Cochrane library, WebMD.com, and World Health Organization Hinari. It shows that the major reasons of RFBs are emergency surgical operation with unplanned changes, patient high body mass index, and poor communication. To prevent this textile material should be radiopaque marked and must be counted once at the start and twice at the conclusion of all surgical procedures. If the count is incorrect, then radiography or manually re-exploration should be performed. Ultrasonography, computerized tomography, magnetic resonance imaging and radio frequency identification are also used in the proper identification of RFBs. Safety practice should be robust and simple enough to protect patient under the most chaotic of circumstances. Proper communication among the personnel participating in surgery aimed at preventing this medical negligence would help in mitigating such errors. Finally, the surgeon should not only follow the standard recommended procedure, but also report cases of RFBs.

Natural history of retained surgical items supports the need for team training, early recognition, and prompt retrieval

BACKGROUND

Unintentionally retained items feature prominently among surgical "never events." Our knowledge of these rare occurrences, including natural history and intraoperative safety omission or variance (SOV) profile, is limited. We sought to bridge existing knowledge gaps by presenting a secondary analysis of a multicenter study focused on these important aspects of retained surgical items (RSIs).

METHODS

This is a post hoc analysis of results from a multicenter retrospective study of RSIs between January 2003 and December 2009. After excluding previously reported intravascular RSIs (n = 13), a total of 71 occurrences were analyzed for (1) item location and type; (2) time to presentation and/or discovery; (3) presenting signs and symptoms; (4) procedure and incision characteristics; (5) pathology reports; and (6) patterns of SOVs abstracted from medical and operative records. These SOV were then grouped into individual vs team errors and single- vs multifactorial occurrences.

RESULTS

Among 71 cases, there were 48 women and 23 men. Mean patient age was 49.7 ± 17.5 years (range 19 to 83 years). Mortality was 4 of 71 (5.63%, only 1 attributable to RSI). Twelve cases (16.9%) occurred at nonparticipating referring hospitals. Most RSI procedures (62%) occurred on the day of hospital admission. The median time from index RSI case to retained item removal was 2 days (range <1 to >3,600 days, n = 63). Abdominal RSIs predominated, and plain radiography was the most common identification method. Most RSIs removed early (<24 hours, n = 23) were asymptomatic. The most common clinical/diagnostic findings in the remaining group were focal pain (n = 22), abscess/fluid collection (n = 18), and mass (n = 8). Most common pathology findings included exudative reaction (n = 22), fibrosis (n = 17), and purulence/abscess (n = 15). On detailed review of intraprocedural events, most RSI cases were found to involve team/system errors (50 of 71) and 2 or more SOVs (37 of 71). Isolated human error was seen in less than 10% of cases.

CONCLUSIONS

The finding that most operations complicated by RSIs were found to involve team/system errors and 2 or more SOVs emphasizes the importance of team safety training. The observation that early RSI removal minimizes patient morbidity and symptoms highlights the need for prompt RSI identification and treatment. The incidence of inflammation-related findings increases significantly with longer retention periods.

A retained plastic protective cover mimicking malignancy: Case report

INTRODUCTION

Cases of retained foreign bodies during surgery are more frequently seen in developing countries. Following surgical procedures, unintentionally retained foreign bodies can cause serious complications, in addition to medico-legal issues.

PRESENTATION OF CASE

A 60-year-old man presented with abdominal cramps. He had previously undergone a laparoscopic radical right nephrectomy due to renal cell carcinoma. Abdominal tomography revealed a mass surrounding the main vascular structures with malignant features in the location of previously performed nephrectomy. Further evaluation of the mass was undertaken by PET/CT. Increased FDG uptake on the PET/CT scan suggested disease recurrence. Retroperitoneal lymph node dissection was performed. The dissection specimen was opened to determine the nature of the mass. Retained plastic foreign bodies were found. There were no malignant cells in the histopathological examination of the surgical specimen.

DISCUSSION

A granulomatous reaction which is mainly responsible for morbidity occurs around the foreign bodies due to the inflammatory response. These granulomas may cause confusion during patient follow-up, especially in those who have undergone major abdominal surgery due to cancer.

CONCLUSION

Following surgical resection for malignancy, unintentionally retained foreign bodies can produce a moderate increase in FDG uptake mimicking disease recurrence.

Foreign body reaction to a retained surgical sponge (gossypiboma) mimicking an implant associated sarcoma in a dog after a tibial plateau levelling osteotomy

A dog was presented with the complaint of an acute onset left pelvic limb lameness three years after a right tibial plateau levelling osteotomy had been performed. Radiographs taken at the time of presentation showed signs that were consistent with a diagnosis of an implant associated sarcoma. At revision surgery, a retained surgical sponge was identified, leading to a diagnosis of a gossypiboma. This is the first reported case of a gossypiboma as a complication of a tibial plateau levelling osteotomy surgery.

Failure to heal of thyroidectomy wound due to gossypiboma and stitch sinus: report of two cases

This case series presents two females, 53 and 33 years old, with thyroidectomy wounds that failed to heal, 16 and 18 weeks, respectively, following the operation. The wounds were explored with removal of gauze and catgut suture. The patients made remarkable improvement and the wounds healed satisfactorily within seven days. Surgical materials forgotten intraoperatively, wrong use of and / or infected surgical materials should be considered when surgical wounds fail to heal.

Beyond a gossypiboma

Gossypiboma or a retained surgical sponge is a rare but avoidable surgical complication. It leads to considerable morbidity and at times even mortality. We report a case of a 24-year-old lady who presented one month after a Caesarean operation with complaints of fever, pain in abdomen, and vomiting. After the clinical examination a possibility of a retained surgical sponge was entertained. However a CT scan of abdomen revealed the complete diagnosis and helped in treating the patient surgically with a successful outcome. A review of the literature and all the relevant issues in the management of such a case have been discussed.

Retained intra-abdominal artery forceps - An unusual cause of intestinal strangulation

CONTEXT

Surgical instruments and materials continue to be retained in the peritoneal cavity despite precautionary measures. Even though uncommon it is also under-reported and carries serious medico-legal consequences. Gauzes and sponges (gossypiboma) are the most commonly retained materials and intra-abdominal retained artery forceps are much rarer but when they do occur lead to chronic abdominal pain and can be a rare cause of intestinal obstruction or strangulation with significant morbidity and mortality.

CASE REPORT

We present a case of intraabdominal retained artery forceps in a 70-years-old lady who underwent laparotomy with splenectomy for a large spleen in a peripheral hospital. Upon discharge she continued to complain of intermittent abdominal pain of increasing severity. 12 months later she presented to us with an acute (surgical) abdomen requiring another laparotomy. At laparotomy she had strangulated/gangrenous lower jejunual and upper ileal bowel loops, the small bowel mesentery of this area being tightly trapped between the jaws of the retained artery forceps. She had gut resection and enteroanastomosis. Unfortunately she died from continuing sepsis on the second post-operative day.

CONCLUSION

Retained instruments in intra-abdominal surgery can cause serious complication and should be treated surgically. High index of suspicion and appropriate investigations like plain abdominal X-ray, abdominal ultrasound and CT and MRI scans should be instituted in patients who develop chronic abdominal symptoms following laparotomy. Preventive measures against retained instruments must follow strict laid down protocols for surgical instruments handling in theatre.

Prevention of retained surgical items

Reduction in retained surgical items is an important part of any operating room patient-safety effort. Any item used in an operation can result in a retained surgical item, but sponges are the most frequent and the abdomen is the most common location. Retained sponges can cause significant morbidity, and the costs associated with both prevention and treatment of retained surgical items, including legal costs, can be considerable. This review will examine counting, teamwork, radiography, and new technology as methods used to prevent retained surgical items. Even though none of these techniques individually is likely to completely prevent retained surgical items, when used together the numbers can be reduced.

Avaliação por imagem dos gossipibomas abdominais

O termo gossipiboma é usado para descrever uma massa formada a partir de uma matriz de algodão cercada por uma reação inflamatória/granulomatosa. Sua incidência é estimada em 0,15% a 0,2%. O corpo estranho na cavidade abdominal pode servir de nicho para a proliferação de microrganismos e agir como foco primário para formação de abscessos e de peritonite. Vários estudos têm demonstrado a importância da correlação clínica com os diversos métodos de imagem (radiografia convencional, ultrassonografia, tomografia computadorizada e ressonância magnética) no diagnóstico dos gossipibomas. Este ensaio tem por objetivo demonstrar uma série de casos típicos de gossipibomas abdominais e ilustrar suas diversas formas de apresentação, com ênfase nos achados dos diferentes métodos de imagem, visando a familiarizar os radiologistas com esta enfermidade e seus principais diagnósticos diferenciais.

Retained surgical swabs in 13 dogs

To report the signalment, history, clinical signs, diagnostic and surgical findings and outcome in dogs and cats with retained swabs, medical records of dogs and cats that were referred to four referral centres were reviewed. Cases in which a retained surgical swab was identified during surgery at the referral hospital were selected for further study. The signalment, history, clinical signs, diagnostic and surgical findings and outcome in these cases were reviewed. Thirteen dogs with retained surgical swabs were included in the study. Bodyweight ranged from 9 to 45 kg. The initial surgery was a 'non-routine' abdominal procedure in seven dogs, ovariohysterectomy in five dogs and perineal hernia repair in one dog. Time from initial surgery to presentation at the referral centre ranged from four days to seven years. Treatment involved major surgery in eight of the 13 dogs. Outcome was excellent in 12 of 13 cases, one dog was euthanased.

Retained surgical sponges: what the practicing clinician should know

Retained surgical sponges (RSS) are an avoidable complication following surgical operations. RSS can elicit either an early exudative-type reaction or a late aseptic fibrous tissue reaction. They may remain asymptomatic for long time; when present, symptomatology varies substantially and includes septic complications (abscess formation, peritonitis) or fibrous reaction resulting in adhesion formation or fistulation into adjacent hollow organs or externally. Plain radiograph may be useful for the diagnosis; however, computed tomography is the method of choice to establish correct diagnosis preoperatively. Removal of RSS is always indicated to prevent further complications. This is usually accomplished by open surgery; rarely, endoscopic or laparoscopic removal may be successful. Prevention is of key importance to avoid not only morbidity and even mortality but also medicolegal consequences. Preventive measures include careful counting, use of sponges marked with a radiopaque marker, avoidance of use of small sponges during abdominal procedures, careful examination of the abdomen by the operating surgeon before closure, radiograph in the operating theater (either routinely or selectively), and recently, usage of barcode and radiofrequency identification technology.

Left behind: unintentionally retained surgically placed foreign bodies and how to reduce their incidence--pictorial review

OBJECTIVE

Unintentionally retained surgically placed foreign bodies have been associated with increased morbidity and mortality, as well as increased costs and medicolegal consequences. This article reviews some of the most commonly retained surgical devices and provides a structured approach to intraoperative image acquisition and interpretation. By increasing the awareness of surgically placed foreign bodies, our goal is to reduce the incidence of and the complications associated with this difficult clinical problem.

CONCLUSION

Despite various systems and safeguards available, unintentionally retained surgically placed foreign bodies remain difficult to eliminate completely. Developing a standardized approach to the request, "intraoperative film, rule out foreign body," is essential to reduce the adverse outcomes associated with this problem.

Gossypiboma of the breast: imaging findings

We report a case of retained surgical sponge in the breast with its sonographic and magnetic resonance (MR) imaging findings. Striped and spotted low signal intensity structures seen within the lesion on T2 weighted MR imaging was characteristic. Sonographic examination also was helpful with the appearance of strong posterior acoustic shadowing at the lesion. It is extremely rare, to see a gossypiboma in the breast. A high degree of suspicion and imaging findings are very important for the diagnosis.

Transmural migration of a surgical compress into the stomach after splenectomy: a case report

A surgical compress retained in the abdominal cavity following surgery is a serious problem. Here, we describe a 33-year-old female who was admitted with abdominal pain, vomiting, no passage of gas or feces, and abdominal distension for 3 days. She had a splenectomy at another medical center 4 years previously. An upright plain abdominal film revealed small bowel obstruction with marked small bowel air-fluid levels. The physical examination revealed muscular guarding and rebound tenderness in the periumbilical region. Therefore, a laparotomy was performed. A surgical compress was removed at enterotomy and the final diagnosis was gossypiboma. Because a retained surgical compress may lead to medicolegal problems, it is important to count the material used before and after a surgical procedure to reduce the risk of this problem.